Peer Support Employment Training Application

Peer Support Employment Training Application Form

If you have one of the following AHCCCS insurance plans, the cost of the course will be covered by your insurance: United Healthcare, Health Choice, Mercy Care, Banner University Family Care, AIHP, and Molina. If you do not have one of the listed plans, the out-of-pocket cost for the course is $600.00.

"*" indicates required fields

Course:*

5 week Friday Course, every Friday from 8am-4pm for 5 weeks. Next Friday course starts July 11, 2025

1 Week, Monday through Friday class from 8am-4pm. Next Course Starts June 9, 2025

Today's Date:*

MM slash DD slash YYYY

Name of Applicant:*

Date of Birth:

MM slash DD slash YYYY

Email Address:*

Phone Number:*

Copy of ID

Max. file size: 50 MB.

Do you have one of these AHCCCS Plans: United Healthcare, Health Choice, Mercy Care, Banner University Family Care, Molina or AIHP?*

Yes

AHCCCS ID:

Copy of front and back of AHCCCS card

Max. file size: 50 MB.

Current Address*

Street City State ZIP / Postal Code Country

Emergency Contact Information

Emergency Contact*

First Last

Emergency Contact Relationship*

Emergency Contact Phone*

Please refer to AHCCCS Policy 963 Attachment B for the Peer Support Employment Training Template referenced below:

Program Providing Peer Support Employment Training: Scottsdale Recovery Center

A. Pre-Screening:

Completing and submitting this application does not guarantee admission into the Peer Support Employment Training. Scottsdale Recovery Center® may have other requirements such as assessments, referrals, additional forms and/or tuition which must be completed or paid prior to starting Peer Support Employment Training. Please contact our peer support team ([email protected]) if you have any questions about eligibility for training.

Please answer the following to the best of your knowledge.

Are you applying to this training program because you intend to practice peer support and deliver peer support services as a PRSS?

Yes

Are you applying to this training program because you intend to practice peer support and deliver peer support services as a PRSS?

Do you understand that the completion of a Peer Support Employment Training program is not a guarantee of employment?

Yes

Do you understand that the completion of a Peer Support Employment Training program is not a guarantee of employment?

Self-identification as a person with lived experiences of behavioral health conditions is a requirement to receive a PRSS credential. Upon completion of this program your name, the name of the training program, date of graduation and current employer (if applicable) will be transmitted to AHCCCS as specified in AMPM Policy 963, Attachment C. This is not considered health information and evidence of a credential may be shared with potential employers and others without a release of information. Please mark yes to attest that you understand and agree to this.

Yes

*Most employers require their new hires to have a High School Diploma or General Education Development (GED). Read the following and check the box that is true for you:*

I have a High School Diploma or GED.

I am in the process of obtaining a High School Diploma or GED.

I do not have, but would like to obtain, a High School Diploma or GED.

I do not have, nor am I interested in obtaining, a High School Diploma or GED.

B. Purpose of Training:

This training is intended to prepare you to practice and deliver peer support services in the AHCCCS (Medicaid) programs.

1. Please describe when and why you have decided to become a Peer Recovery Support Specialist?

2. What are you looking forward to most about this training?

3. A PRSS often spends a lot of time doing paperwork and may have other duties unrelated to practicing and delivering peer support services. What concerns, if any, do you have about this?

4. Some work environments may seem more recovery-oriented and more welcoming than others. What concerns, if any, do you have about working in environments that you may feel are less Recovery-Oriented and less- welcoming?

C. Self-Identification:

A Peer and Recovery Support Specialist (PRSS) is an individual who has lived experience of mental health conditions, substance use and/or other traumas resulting in emotional distress and life disruption, for which they have sought support; and can demonstrate their own efforts at self-directed recovery and expertise, including knowledge of approaches to support the recovery of others.

Read the following statements and tell us if they are true or not true, for you.

"I willingly self-identify to others as having lived experience of mental health conditions, substance use and/or other traumas resulting in emotional distress and life disruption, for which I have sought some type of help or care."

Yes,
this is true for me.

No,
this is not true for me.

"I am actively engaged in my own recovery, healing, and wellness practices."

Yes,
this is true for me.

No,
this is not true for me.

"I am actively sustaining my own recovery and/or healing process; and managing my own wellness."

"I am willing to share these lived experiences, when appropriate, for purposes of education, role modeling and providing hope to others about the reality of recovery."

Yes,
this is true for me.

No,
this is not true for me.

"I am willing to share these lived experiences, when appropriate, for purposes of education, role modeling and providing hope to others about the reality of recovery."

Personal Recovery:

The following Yes/No questions relate to how you practice your own recovery. Answering "YES" to any of the following questions means that you are willing to share your response at a later date. You will NOT be asked to share your response at this time.

Are you willing to share what you have had to overcome to get where you are today?

Yes

Are you willing to share what you have had to overcome to get where you are today?

Are you willing to share what having “lived experience” means to you? Are you willing to share some of the beliefs and values you have, or have developed, which help to strengthen your recovery?

Yes

Are you willing to share what having “lived experience” means to you? Are you willing to share some of the beliefs and values you have, or have developed, which help to strengthen your recovery?

D. Commitment to Training Participation and Accommodation:

This training program requires complete attendance for the duration of the training. If accepted to the program, can you commit to the attendance requirement?

Yes

This training program requires complete attendance for the duration of the training. If accepted to the program, can you commit to the attendance requirement?

Are there any barriers which may keep you from attending the entire training (e.g., childcare, work schedule, transportation)?

Yes

Are there any barriers which may keep you from attending the entire training (e.g., childcare, work schedule, transportation)?

If yes, please describe:

The training is highly interactive and requires activities involving small group work, role-playing, and reading aloud to the class. Are you comfortable with this kind of participation?

Yes

The training is highly interactive and requires activities involving small group work, role-playing, and reading aloud to the class. Are you comfortable with this kind of participation?

As part of the training, you will be asked to participate in discussions, role-plays, and to share your personal story of recovery in front of the class. Are you comfortable with this kind of participation?

Yes

During the training you will listen to the recovery stories of others. Sometimes these stories may be uncomfortable to hear. Are you willing to communicate any discomfort to the trainers if this were to happen?

Yes

If any of the above is challenging to you, how do you think you will approach it?

Are there any accessibility needs for you to fully participate in the training? (e.g., service animal, note taker, large text, sign language interpreter)?

Yes

Are there any accessibility needs for you to fully participate in the training? (e.g., service animal, note taker, large text, sign language interpreter)?

E. Attestations:

Please check to attest you understand and agree to the below statements:*

I understand that a PRSS Credential is not health information and is necessary for employment and delivering services as a PRSS. Evidence of my credential may be shared with potential employers and others without a release of information.

Please check to attest you understand and agree to the below statements:*

I understand that Scottsdale Recovery Center requires 90 days of continuous sobriety to register for and begin peer support employment training. I understand that I must maintain my sobriety for the duration of the course.*

Please check to attest you understand and agree to the below statements:*

I understand that I will be required to take a competency exam at the end of the training, and I must receive a passing score of 80% or more to receive my peer credentials. If I do not receive a passing grade, I may apply to take the exam over 1 time. If I do not receive a passing score the 2nd time, I may be required to take/review specific portions based on trainer discretion. Failure to receive a passing score after retesting the 3rd time will result in taking the course again prior to retesting (or further accommodations may be made at the discretion of the trainer).*

Please check to attest you understand and agree to the below statements:*

I have answered the questions in this application truthfully, and to the best of my ability.*

Printed Name*

Digital Signature*

Date*

MM slash DD slash YYYY

71917

Scottsdale Recovery Center, Thrive for Greatness in Your New Found Sobriety.
Trust Arizona’s Treatment Leader, Scottsdale Recovery Center.

Peer Support Employment
Training Application